Facility Evaluation Report

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with Executive Director, Johnny Ortiz. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20241230123842. During the complaint investigation, the following deficiencies were observed:

During today’s visit LPA reviewed and compared the Personnel Report (LIC500), LIS system and the Guardian System. During the audit, LPA observed two (2) staff members listed on the Personnel Report (LIC500) that have passed a criminal background clearance, however, they were not properly associated to the facility. LPA was able to look-up employee information in the LIS system and found that Staff #1 has been working at the facility since 06/13/2022 and Staff #2 (S2) has been working since 05/16/2024. Both staff members were separated from facility named above. S1 separation date was 07/01/2023 and S2 was separated on 05/22/2023. ED stated that S1 is not longer an employee for the facility since 03/16/2025 and during today's visit S2 was associated to the facility. Additionally, LPA requested the Personnel Report (LIC 500) for the month of December 2024. However ED was unable to produce this information stating that they were not aware that the facility is required to keep a current roster of all facility personnel.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Citations issued, civil penalty issued, exit interview, appeal rights given.